Managed Care

California’s Reboot of Troubled Medi-Cal Puts Pressure on Health Plans

When Denise Williams’ baby boy was 2 months old, she became alarmed by a rattling sound in his lungs and took him to the emergency room. While undergoing treatment, he spiraled into a disabling neurological disorder. Now 2 years old, Markeano is attached to breathing and feeding tubes. He can’t walk or move his arms. …

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Medicaid Authorities and Options to Address Social Determinants of Health (SDOH)

Extensive research and the pandemic have elevated the importance of addressing social determinants of health (SDOH) to improve health and reduce longstanding disparities in health and health care. Social determinants of health include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. This …

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How ICER will conduct it’s “Barriers to Fair Access” Assessment

Last fall, ICER published a white paper titled “Cornerstones of ‘Fair’ Drug Coverage: Appropriate Cost-Sharing and Utilization Management Policies for Pharmaceuticals.” To paraphrase, ICER’s goal is to limit access restrictions (e.g., cost sharing, coverage limitations, prescriber restrictions, step therapy) when a drug is deemed to be cost effective. How will they do this? Their Barriers …

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Potential Implications of Policy Changes in Medicaid Drug Purchasing

This brief examines how leading federal and state policy options related to changes in Medicaid Drug Rebate Program (MDRP), drug pricing, and payment and management of the Medicaid prescription drug would affect state and federal governments as well as private industry (including drug manufacturers, managed care organizations, and pharmacies).

Health Insurer Financial Performance in 2020

This analysis examines insurers’ financial data across markets through the end of 2020. It finds that average margins remained relatively high compared to recent years, suggesting many insurers remained profitable even as health spending rebounded and COVID-19 cases surged in the fall and winter.

Meet Circulo, the insurtech firm on a mission to disrupt Medicaid managed care

A new startup has entered the highly competitive insurtech market — with $50 million in new funds. Circulo, co-founded by Olive CEO Sean Lane, is a Medicaid managed care company that plans to build a platform to improve care delivery and member experience.

Health Insurer Financial Performance Through September 2020

In this brief, we analyze third quarter data from 2018 to 2020 to examine how insurance markets performed financially through the end of September. Average margins remained relatively high compared to the same point in recent years, suggesting many insurers remained profitable even as non-COVID-related care returned in the summer and fall.

Growth in Medicaid MCO Enrollment during the COVID-19 Pandemic

This data note looks at state Medicaid managed care enrollment data through September 2020 to assess the impact of the COVID-19 pandemic and economic crisis on Medicaid enrollment. Data collected for 30 states show Medicaid managed care enrollment increased to 11.3% from March 2020 through September 2020. The rate accelerated from the 4.1% reported for …

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CMS’s 2020 Final Medicaid Managed Care Rule: A Summary of Major Changes

On November 13, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized revisions to the Medicaid managed care regulations which were proposed in November 2018. CMS previously finalized a major revision to these regulations in 2016. The November 2020 final rule is not a wholesale revision of the 2016 regulations but adopts changes in …

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CMS’s 2020 Final Medicaid Managed Care Rule: A Summary of Major Changes

On November 13, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized revisions to the Medicaid managed care regulations which were proposed in November 2018. CMS previously finalized a major revision to these regulations in 2016. The November 2020 final rule is not a wholesale revision of the 2016 regulations but adopts changes in …

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The problem with prior authorization

Prior authorization is a requirement that health plans require physicians to obtain plan approval in order to prescribe a patient a given medication. Prior authorizations may be put in place to insure medications are not used inappropriately or for payers to try to reduce cost. While prior authorization may help save money, delays in the …

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